A. Symptoms of Esophageal Disease [4]

1. Dysphagia: difficulty swallowing
   1. Foods usually affected first
   2. Liquids affected with complete occlusion
2. Odynophagia: Pain on swallowing
3. Regurgitation of ingested food
   1. Most common is gastroesophageal reflux (GERD) or "heartburn"
   2. Rumination syndrome may be mistaken for this in some persons [5]
   3. Occurs with diverticulae as well (food is trapped, then regurgitated up)
   4. May occur with esophageal spasm
4. Fullness in chest area - atypical chest pain
5. Angina-like chest pain is not typical of esophageal disease [7]

B. Tests

1. Radiocontrast Study
   1. Barium or Gastrograffin Swallow (Upper GI Series)
   2. Video Swallowing Study
2. Upper Endoscopy (esophagogastroduodenoscopy or EGD)
3. Manometry
4. pH probe
5. Berstein Test - acid provocation
6. Impedance Planimetry - hyperreactive esophagus [8]

C. Disease Entities

1. Gastroesophageal Reflux Disease (GERD) [1,2]
   1. Very common, particularly with increasing age
   2. Sour taste in mouth, "heartburn", pain through chest to back
   3. Aggrevated by hiatal hernia and nonsteroidal anti-inflammatory drugs (NSAIDs)
   4. May lead to stricture, metaplasia (Barrett's Esophagus), adenocarcinoma
2. Motility Disorders [10]
   1. Achalasia - progressive dysphagia with both food and liquids
   2. Diffuse Esophageal Spasm (DES) - odynophagia (angina like) and regurgitation
   3. Scleroderma - usually with reflux disease
3. Dysphagia
   1. Usually evaluate dysphagia with barium swallow first
   2. Solids but not liquids - suggests anatomic obstruction
   3. Anatomic obstruction in younger persons: usually Schatzki (lower esophageal) ring
   4. Anatomic obstruction in older persons: usually carcinoma in older persons
   5. Schatzki ring is essentially non-progressive
   6. Peptic Stricture - slow progression from solids to include liquids
   7. Carcinoma - Rapidly progressive from solids to liquids, often with weight loss
4. Webs and Rings
   1. Congenital or inflammatory
   2. Schatzki Ring (see below)
   3. Lower esophageal muscular ring - contractile ring
   4. Hypopharyngeal webs - often asymptomatic; found in ~10% of normal persons
   5. Plummer-Vinson Syndrome
   6. Symptomatic hypopharyngeal webs with dysphagia
      1. Glossitis
      2. Iron Deficiency Anemia
   7. Stricture / Ring Stenosis [6]
   8. Due to chronic irritation
      1. Most commonly Barrett Esophagus
      2. Increased risk for esophageal adenocarcinoma
5. Schatzki Ring
   1. Lower esophageal mucosal ring, weblike, near gastroesophageal junction
   2. Constriction progresses with aging
   3. Symptoms of dysphagia solids >> liquids begin at diameters 1-1.5cm
   4. Treat with dilatation
6. Diverticuli
7. Varices
8. Boerhave Syndrome - esophageal perforation
9. Fistula [3]
   1. Tracheoesophageal Fistula
   2. Bronchoesophageal Fistula
   3. Cough, regurgitation, fever, recurrent infection, pain, fullness
10. Carcinoma
11. Rumination Syndrome [5]
    1. Rumination is repetative regurgitation of small amounts of food from stomach
    2. Occurs in ~20% of patients with bulimia
    3. Bulimics tend to expel food out of their mouths when they ruminate

D. Esophageal Disease in HIV [9]

1. Candidal Esophagitis - most common
2. Esophageal Ulcerations
   1. Cytomegalovirus (CMV)
   2. Idiopathic
3. Herpes Simplex Infection
4. Other fungal pathogens
5. Kaposi Sarcoma

References

1. Spechler SJ. 1992. NEJM. 326:726
2. Mittal RK and Balaban DH. 1997. NEJM. 336(13):924
3. Kaul DR, Orringer MB, Saint S, Jones SR. 2007. NEJM. 356(18):1871 (Case Discussion)
4. Pope CE II. 1997. Am J Med. 103(5A):19S
5. Malcolm A, Thumshirn MB, Camilleri M, Williams DE. 1997. Mayo Clin Proc. 72(7):646
6. Spechler SJ. 1994. Semin Oncol. 21:431
7. Frobert O, Funch-Jensen P, Bagger JP. 1996. Ann Intern Med. 124(11):959
8. Rao SS, Gregersen H, Hayek B. et al. 1996. Ann Intern Med. 124(11):950
9. Wilcox CM, Straub RF, Alexander LN, Clark WS. 1996. Am J Med. 101(6):599
10. Richter JE. 2001. Lancet. 358(9284):823